Research article EMHJ – Vol. 26 No. 7 – 2020 Estimating the incidence rate of hepatitis B and C in East Azerbaijan, Islamic Republic of Iran Mohammad Hossein Somi,1 Simin Khayatzadeh,2 Mohammad Nalbandy,2 Shahnaz Naghashi 1 and Zeinab Nikniaz 1 1Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 2East Azarbaijan Provincial Health Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. (Correspondence to: Zeinab Nikniaz: [email protected]). Abstract Background: The World Health Organization (WHO) has aimed for a 30% reduction in hepatitis B (HBV) and hepatitis C (HCV) incidence by 2020. To achieve this goal, it is important to have updated information about trends in the hepatitis incidence rate. However, there is a lack of up-to-date data from East Azerbaijan province in the Islamic Republic of Iran. Aims: This study aimed to estimate the HBV and HCV incidence rate from 2011 to 2016 in East Azerbaijan, Islamic Repub- lic of Iran. Methods: Hepatitis data and population data were obtained respectively from the national notifiable disease surveillance system and the national Iranian census for 2016. For quantifying the rate of changes in incidence rate from baseline, the average annual rate of reduction (AARR) was calculated. For this, the linear regression model was used for estimating the beta coefficient. SPSS V25 was used for statistical analysis. Results: Over the 6-year period, 3119 hepatitis cases in East Azerbaijan province were reported, of which 94.7% were hep- atitis B. The majority of the affected individuals were 25–44 years old. HBV incidence was reduced by 12.71% annually between 2011 and 2016. However, the number of HCV patients increased during 2014–2016, and HCV incidence rate in- creased insignificantly (β = 0.109, P = 0.39). Conclusion: There is a significant downward trend of HBV in East Azerbaijan due to mass vaccination programmes. In the case of HCV, when considering the availability of effective treatment regimens in addition to education and preven- tion programmes, policy-makers should focus on HCV screening and diagnosis, especially in the 25–44 age group. Keywords: Hepatitis B, Hepatitis C, incidence, infection, Iran Citation: Somi MH; Khayatzadeh S; Nalbandy M; Naghashi S; Nikniaz Z. Estimating the incidence rate of hepatitis B and C in East Azerbaijan, Islamic Republic of Iran. East Mediterr Health J. 2020;26(7):803–809. https://doi.org/10.26719/emhj.19.077 Received: 31/10/18; accepted: 24/04/19 Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) Introduction improvement in incidence and prevalence rate of viral hepatitis has been expected. There are limited studies in Viral hepatitis is a public health problem worldwide (1). the Islamic Republic of Iran that assess the HBV and HCV According to the World Health Organization (WHO), in incidence trend. In a study in Ilam, Khazaei et al. reported 2015 about 325 million people worldwide were affected the incidence of HBV and HCV during 2008–2013 and by acute viral hepatitis, from which 275 million cases showed an increasing trend in HBV and HCV incidence were related to chronic hepatitis B (HBV) and 71 million (7). However, in a study in Hamadan during 2004–2009, cases were related to hepatitis C (HCV) (2,3). Considering a decreasing trend of HBV and HCV was reported (8). the high burden of hepatitis, WHO has aimed for a 30% In East Azerbaijan, one of the most populous Iranian reduction in the incidence of HBV and HCV by 2020 and provinces, the prevalence of HBV and HCV was reported a 90% reduction by 2030 (3). to be 1.2% in 2000 (9). However, no updated report about The Eastern Mediterranean Region (EMR) countries its prevalence or incidence is available. have more than 15 million affected people and had the Considering the importance of having updated highest prevalence of HCV infection (4). Moreover, in information about the prevalence and incidence of hepatitis this Region 21 million people had HBV (4). However, the for the planning of prevention and treatments programmes, Islamic Republic of Iran has a relatively low endemicity (5). and the lack of studies in this regard in East Azerbaijan, this The prevalence of HBV varied across the Iranian study was conducted with the aim of evaluating the trend provinces; the highest prevalence was reported in of incidence rate of HBV and HCV during 2011–2016 in East Golestan province (6.1%, 95% CI: 3.5–8.7%) (6) and the Azerbaijan, Islamic Republic of Iran. lowest prevalence was reported in Kermanshah (0.7%, 95% CI: 0.4–1.1%) (6). According to a recent systematic review, the pooled estimated prevalence of HBV infection was Methods 2.2 % in the general Iranian population from 1990 to 2016 The data for this retrospective cohort study were obtained (6). By initiating HBV vaccination programmes from 1993 from the national notifiable disease surveillance system and blood donor screening programmes from 1996, the in East Azarbaijan province, which is the northwestern 803 Research article EMHJ – Vol. 26 No. 7 – 2020 province in the Islamic Republic of Iran, and consists of Table 1 Sociodemographic characteristics of the study 19 counties with a population of 3.909 million and bor- participants (n = 1000), Kerman, 2016 ders the Republic of Azerbaijan and Armenia. Variable Total HBV HCV HBV+ According to hepatitis management guidelines, (n=3119) (n=2957, (n=151, HCV 94.7%) 4.9%) (n=11, monthly reporting of hepatitis cases (positive for HBsAg, 0.4%) HBeAg, anti-HBC and anti-HCV positive) from all Sex laboratories, blood transfusion organizations, hospitals, Male 1517 (48.6) 1390 (47.0) 111 (77.0) 9 (81.8) health centres and district health centres are compulsory since 2004. Moreover, a questionnaire that includes Female 1602 (51.3) 1567 (53.0) 33 (22.9) 2 (18.1) demographic characteristics, risk factors, examination Marital status cause and disease status was completed by health staff Married 2776 (89.3) 2669 (90.6) 97 (63.3) 10 (90.9) based on the patient’s interview data. Finally, all data were Single 250 (8.0) 210 (7.1) 39 (26.7) 1 (9.0) registered in the province health centre database. For the Divorced 15 (0.4) 7 (0.3) 8 (5.2) - present study, all subjects with positive HBsAg and anti- Widow 65 (2.0) 58 (1.9) 7 (4.5) - HCV serological markers who registered between 2011 Location and 2016 in East Azerbaijan province were included. Capital city 1374 (44.5) 1296 (43.8) 74 (49) 4 (36.4) For estimating the incidence rate, the total population Suburban areas 1712 (55.4) 1661 (56.2) 77 (51) 7 (63.6) of East Azerbaijan, population of each county and also age-specific population for each year were obtained Risk factors Infection in other from the national Iranian census for 2016. The incidence 644 (20.6) 639 (24.6) 4 (2.6) 1 (9.1) family members rate for each year was calculated by the number of cases Blood transfusion 57 (8.1) 51 (1.7) 6 (4) - reported in a particular calendar year per 100 000 total population. The age-specific and also county-specific Sexual contact 35 (1.1) 11 (0.4) 7 (4.6) - Intravenous drug incidence rate was calculated as follows: (number of 53 (1.7) 11 (0.4) 27 (17.9) 1 (0.9) users new cases) / (person-time at risk). Person-time at risk is Dialysis 36 (1.2) 16 (0.5) 20 (13.2) - calculated as follows: [(number of people at risk at the beginning of the time interval + number of people at risk Mother to child 7 (0.2) 7 (0.2) - - at the end of the time interval) / 2] × (number of years in Health worker 11 (0.4) 11 (0.4) - - the time interval). Others 2250 (72.1) 387 (13.1) 68 (45) 8 (72.7) Non responders 40 (1.3) 37 (1.3) 2 (1.3) 1 (0.9) Statistical analysis Clinical spectrum SPSS V25 and Microsoft excel 2013 were used for statisti- Chronic 2718 (87.8) 2580 (87.9) 129 (86) 10 (83.3) cal analysis. The normality of distribution of continuous Carrier 408 (13.1) 385 (13.3) 20 (13.3) 2 (16.6) variables was tested by using the Kolmogorov-Smirnov Acute 108 (3.4) 99 (3.3) 8 (5.3) 1 (8.3) test. Continuous variables were presented as mean ± standard deviations (SD) and the categorical variables ND 269 (8.6) 255 (8.6) 13 (8.6) 1 (8.3) were presented as frequency (%). For determining the HBV=Hepatitis B virus; HCV=Hepatitis C virus; ND=Not defined average annual rate of reduction or increase (AARR), the regression model was used for estimating beta coeffi- cient and P-value. The log incidence rate and time were were living in suburban areas. The frequency of HBV considered as dependent and independent variables re- was higher in suburban areas; however, the frequency spectively. Then AARR was calculated based on the fol- of HCV was higher in urban areas, and 87.81% of cases lowing formula: AARR= (1-antilog beta)*100. The sign of were chronic. beta indicates the direction of the trend. This method Figure 1 depicts the incidence rate of HBV and HCV was adapted on the basis of information provided in a stratified by year. According to this figure, there was a UNICEF technical note (10). steady decrease in frequency and incidence rate of HBV between 2011 and 2016.